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Home My Public Portal About5719 KAUFFMAN AVE_Sewer__ 1o.e2 76A642D - APPLICATION FOR PERMIT 78A 84 COUNTY OF LOS ANGELES ' SEWER—SEWAGF DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST ^ FOR APPLICANT TO FILL IN CRDBS ST LEGAL / - DESCRIPTION LOT NO. � OWNER L'�Z lr MAIL BLOCK TRACT V ADDRESS NO OF BLDGS. SIZE OF LOT A NOVV, ON LOT CITY TEL NO. 2 93 USE OF f :ISTRICT NO GROUP MAP PROCESj BUILDINGS kkih CONTRACTOR ��-B^K �PG 1 ADDRESS . uV CONNECTIO DATA / STATION DEPTH CITY ,i/ TEL NO 3 a A MANHOLE REFERENCE PPER >_ REGISTRATION NO COUNTY ,. a NO DESCRIPTION OF WORK FEE TYPE OF _ LENG7 OM O HOUSE SEWER CONNECTING TO �) +, Y CURB P.L M L T L. U PUBLIC SEWER @ $5 00 ✓ '✓ SEPTIC TANK,SEEPAGE PIT OR >� P.0 NO Q[ PITS AND/OR DRAINFIELD @ $1000 CO.IMP NO. a JOB NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT Nb}� PRIVATE DISPOSAL SYSTEM @ $300 / YYYJJJ CONN ECT ADDITIONAL BLDG OR _ AFFIDAVIT wAIVEF I EASEMENT RECORD INSTR NO. DATE d WORK TO HOUSE SEWER Q $3.00 LO OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN,CESSPOOL,DRYWELL.M AN HOLE @ $5 00 ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ 33 00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS. PERMIT $1 2 00 CHARGES AUTHORIZATIONI TOTAL FEE n->l CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT T E ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC S E ,{ APPROVALS DATE INSPE 70 S SIGNATURE SIGNED THIS AY OF OWNER OR II A NEW HOUSE SEWER OWNERS AGENT {rte• CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING _ PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY I AM L REGIST RED AND/OR ALTER, REPAIR,SEWER OR LICENSED AS REOU BY LOS NGLE OUNTY AND STATE F SE WAGE DISPOSAL SYSTEM CALIFORNIA OR TH AM THE 'EGAL R OF, AND INTE TO DISCONNECT PLUG AND ' RESIDE IN, THE E 'DESCRIB D R E TIAL RTY. ABANDON HOUSE,SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PER SEEP.PIT(S) ❑ CESSPOOLS ❑ ATI O ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER + M O. CASH 0 4-8 9 :SEP1 0 D 7 ?0`� WORKERS'COMPENSATION DECLARATION 76A642D APPLICATION FOR PERMIT {� CE 808 (2-80) LJ I hereby affirm that I have a certificate of consent to self SEWER—SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANTTO FILL IN CONNECTION DATA BUILDING ADDRESS DEPTH ❑ Certified copy is filed with the county building inspection UPPER department' LOCALITY MANHOLE REFERENCE LOWER Date Applicant NEARESTTYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P,L. COMPENSATION INSURANCE P.C. NO. I OWNER CO. IMP. NO. JOB NO } MAIL (This section need not be completed if the work involved ADDRESS /� TRUNK PERMIT NO. ROAD PERMIT NO. O by the permit is for one hundred dollars (SI00) or less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE U CITY TEL. NO. _ I certify that in the performance of the w rk for which this LEGAL IY permit is issued, I shall'not employ any p son ' any manner DESCRIPTION LOT NO. �' HWY. OR ST. WIDENING so as to become subject to the Worke ' Com nsatio Laws U pp BLOCK TRACT STATE ENCROACHMENT W Dat A licant NO. OF BLD GS. PERMIT NO. rn NOTICE TO APPLICANT. If, after.making this ertificate o SIZE OF LOT NOW ON LOT z Exemption, USE OF p you should become subject to the Worker ' BUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth- with comply with such provisions Or this permit shall be CONTRACTORO u I CONNECTION CHARGE FEE deemed revoKed. /� REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS 4,,�2.3 ,�il/(�' { % �'P _/� DISTRICT NO. GROUP � MAP PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter clrY ��rEL. NO. 28� J p`' BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE ��S—�f LIC. ( . 41Or 1% � effect. LICENSE NO. CLASS b �j NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL ('1 VALIDATION License Number Lic.Class PUBLIC SEWER DATE /l! SEPTIC TANK,SEEPAGE PIT OR Contractor Date PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY ❑ - I am exempt from the licensing requirements as I am a PRIVATE DISPOSAL SYSTEM ONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO MOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD In CSS and PIOfCSSIOnS Code). EXT..,CESSPOOL,DRYWELL,MANHOLE V , ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I he affirm that I am exempt from the Contractor's OWNERS Permit f License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE I I fe, ness and Professions Code): , I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR ON- 1'RACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do ttie work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 i 7044, Business and Professions Code).- OWNER OR 3 0 U 9 A OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency # o'o!o o 0 for the performance of the work for which this permit is t issued(Sec. 3097,Civ.C.). 2'o,- r00 ,7,Jr 0•. Lender's Name Lender's Address o oro :7 5 I certify that I have read this application and state that the 0 2 2 3,—8 2 above information is correct. I agree to comply with all County ordinances and tate laws regulating Plumbing and Sewers, and hereby au orize r resentati es of this County to enter upon the ab -mentio d pr pe y for Inspection purpose2t �? s. 9� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte Date ' I